Date of report: 22 April 2020

Ref: 2020-0100

Deceased name: David Kerr

Coroners name: Jason Wells

Coroners Area: Manchester South

Category: Other related deaths; Hospital Death (Clinical Procedures and medical management) related deaths

This report is being sent to: Stockport NHS Foundation Trust

Matters of concern:

  1. DK’s medical care on ward D2 was poor and probably contributed to his death.
  2. Between 24th and 26th April DK was allowed to become increasingly dehydrated; on 24th April he received a total of 300mls of fluid and the input/output chart was not filled in on 25th/26th April, despite the fact that he was seriously unwell.
  3. There were few clinical observations on this sick patient. On 26th April, clinical observations were performed at 11.12 (MEWS 1) and 21.06 (MEWS 0). There were no clinical observations thereafter. No protocol was produced regarding the frequency of observations in sick patients on Ward D2.
Regulation 28: Report to prevent future deaths: David Kerr
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Regulation 28: Report to prevent future deaths: David Kerr – Courts and Tribunal Judiciary